Background—: In the era of drug-eluting stents, it is unknown if intravascular ultrasound (IVUS) guidance for percutaneous coronary intervention should be routinely endorsed. This study aimed to determine if IVUS-guided stent implantation is associated with improved outcomes. Methods and Results—: Randomized trials that reported clinical outcomes and compared routine IVUS-guided stent implantation with an angiography-guided approach in the era of drug-eluting stents were included. Summary estimates were constructed primarily using the Peto model. Seven trials with 3192 patients were analyzed. The mean length of the coronary lesions was 32 mm. At a mean of 15 months, routine IVUS-guided percutaneous coronary intervention was associated with a reduction in the risk of major adverse cardiac events (6.5% versus 10.3%; odds ratio, 0.60; 95% confidence interval, 0.46–0.77; P <0.0001), mainly because of reduction in the risk of ischemia-driven target lesion revascularization (4.1% versus 6.6%; odds ratio, 0.60; 95% confidence interval, 0.43–0.84; P =0.003). The risk of cardiovascular mortality (0.5% versus 1.2%; odds ratio, 0.46; 95% confidence interval, 0.21–1.00; P =0.05), and stent thrombosis (0.6% versus 1.3%; odds ratio, 0.49; 95% confidence interval, 0.24–0.99; P =0.04) also appeared to be lower in the IVUS-guided group. Conclusions—: In the era of drug-eluting stents for diffuse coronary lesions, IVUS-guided percutaneous coronary intervention is superior to angiography-guided percutaneous coronary intervention in reducing the risk of major adverse cardiac events. This is primarily because of reduction in the risk of ischemia-driven target lesion revascularization. This analysis also suggests that risk of cardiovascular mortality and stent thrombosis might be lower with an IVUS-guided approach.

Background: Concerns about discordance between echocardiographic and invasive mean gradients after transcatheter aortic valve replacement (TAVR) with balloon‐expandable valves (BEVs) versus self‐expanding valves (SEVs) exist. Methods and Results: In a multicenter study, direct‐invasive and echocardiography‐derived transvalvular mean gradients obtained before and after TAVR were compared as well as post‐TAVR and discharge echocardiographic mean gradients in BEVs versus SEVs in 808 patients. Pre‐TAVR, there was good correlation ( R =0.614; P <0.0001) between direct‐invasive and echocardiography‐derived mean gradients and weak correlation ( R =0.138; P <0.0001) post‐TAVR. Compared with post‐TAVR echocardiographic mean gradients, both valves exhibit lower invasive and higher discharge echocardiographic mean gradients. Despite similar invasive mean gradients, a small BEV exhibits higher post‐TAVR and discharge echocardiographic mean gradients than a large BEV, whereas small and large SEVs exhibit similar post‐TAVR and discharge mean gradients. An ejection fraction <50% ( P =0.028) and higher Society of Thoracic Surgeons predicted risk of mortality score ( P =0.007), but not invasive or echocardiographic mean gradient ≥10 mm Hg ( P =0.378 and P =0.341, respectively), nor discharge echocardiographic mean gradient ≥20 mm Hg ( P =0.393), were associated with increased 2‐year mortality. Conclusions: Invasively measured and echocardiography‐derived transvalvular mean gradients correlate well in aortic stenosis but weakly post‐TAVR. Post‐TAVR, echocardiography overestimates transvalvular mean gradients compared with invasive measurements, and poor correlation suggests these modalities cannot be used interchangeably. Moreover, echocardiographic mean gradients are higher on discharge than post‐TAVR in all valves. Despite similar invasive mean gradients, a small BEV exhibits higher post‐TAVR and discharge echocardiographic mean gradients than a large BEV, whereas small and large SEVs exhibit similar post‐TAVR and discharge mean gradients. Immediately post‐TAVR, elevated echocardiographic‐derived mean gradients should be assessed with caution and compared with direct‐invasive mean gradients. A low ejection fraction and higher Society of Thoracic Surgeons score, but not elevated mean gradients, are associated with increased 2‐year mortality.

Background—: It is unclear whether intravenous glycoprotein IIb/IIIa inhibitors or ischemic time might modify any clinical benefits observed with aspiration thrombectomy before primary percutaneous coronary intervention (PCI) in patients with ST-segment–elevation myocardial infarction. Methods and Results—: Electronic databases were searched for trials that randomized ST-segment–elevation myocardial infarction patients to aspiration thrombectomy before PCI versus conventional PCI. Summary estimates were constructed using a DerSimonian-Laird model. Seventeen trials with 20 960 patients were available for analysis. When compared with conventional PCI, aspiration thrombectomy was not associated with a significant reduction in the risk of mortality 2.8% versus 3.2% (risk ratio [RR], 0.89; 95% confidence interval [CI], 0.76–1.04; P =0.13), reinfarction 1.3% versus 1.4% (RR, 0.93; 95% CI, 0.73–1.17; P =0.52), the combined outcome of mortality or reinfarction 4.1% versus 4.6% (RR, 0.90; 95% CI, 0.79–1.02; P =0.11), or stent thrombosis 0.9% versus 1.2% (RR, 0.82; 95% CI, 0.62–1.08; P =0.15). Aspiration thrombectomy was associated with a nonsignificant increase in the risk of stroke 0.6% versus 0.4% (RR, 1.45; 95% CI, 0.96–2.21; P =0.08). Meta-regression analysis did not identify a difference for the log RR of mortality, reinfarction, and the combined outcome of mortality or reinfarction with intravenous glycoprotein IIb/IIIa inhibitors ( P =0.17, 0.70, and 0.50, respectively) or with ischemic time ( P =0.29, 0.66, and 0.58, respectively). Conclusions—: Aspiration thrombectomy before primary PCI is not associated with any benefit on clinical end points and might increase the risk of stroke. Concomitant administration of intravenous glycoprotein IIb/IIIa inhibitors and ischemic time did not seem to influence any potential benefits observed with aspiration thrombectomy.

Transcatheter aortic valve replacement (TAVR) has become standard therapy for patients with severe aortic stenosis who are deemed at least intermediate risk for surgical valve replacement. Over the past decade, several technological advances have taken place to improve the quality and safety of these devices. The current commercially available valves are broadly grouped into balloon expandable and self-expandable valves. The latest iteration of the self-expandable valve is Medtronic’s repositionable valve known as the Evolut PRO system. In this review, we highlight the evidence behind the use of TAVR, improvement in devices over previous generations, clinical evidence behind the CoreValve Evolut PRO system, and the future of TAVR.